CHAPTER SEVEN

PROGRAM ACCEPTANCE BY THE AKHAS

 

Acceptance of Reversible Contraceptives

 

Acceptance of family planning services among the Akhas is purely a personal or family decision, rather than a decision made by village leaders.  To what degree have Akhas accepted these services?  On the whole, the response has been greater than we had hoped.  Table 3 (page 128) indicates the rate of acceptance of contraceptive aid (both oral and injectable) from the Akha field worker in Thailand from December 1973 through July 1977.

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(to add below)----Table 3:  Acceptance of contraception by Akhas  {footnote 1:  There were no contraceptive injections given by our program to tribal women in Burma.  Oral contraceptives have been sent to Burma, but their distribution is not included here.  All sterilizations were performed in Thailand, although 170 Akha women came from Burma for the operation, following which they returned home.}

 

                                                    Acceptance of Oral Contraceptives

 

Oral contraceptives were offered to women who wished to limit pregnancies, provided: 1) their husbands agreed, and 2) there were no physical indications (such as high blood pressure) that might counterindicate the pills being taken.  Even those women who never had a pregnancy could take pills.  We did not recommend pills to women nursing infants, or to women over forty years of age.  Oral contraceptives have proven to be an excellent means of preventing pregnancy in many societies (Houghie 1969, Spiedel, Ravenholt and Irvine 1974, Nelson 1971, Connel 1970), so when the program started, I thought this would be the main method Akha couples would use.  However, it was not popular for two reasons:

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1) There are side effects for some women, and 2) they find it difficult to take a pill each night (see page 93).

 

Another problem with the pills is that a woman who is on pills often stops taking them any time she becomes ill.  An Akha woman originally on pills told me that she had had a difficult time taking them, because something was always going wrong, so she would stop.  It turned out that any time she or any member of her family got sick, she felt she should quit taking the pills.

 

Two Akha women once asked me if there was a contraceptive pill to be taken once a month rather than every night.  They felt that they could remember to take the pill at monthly intervals.  Such pills have been in use in Latin America since 1966 (Berman 1970: 196), but they are not available in Thailand.  Even if they were, there would still be the problems of: 1) potential side effects, 2) influence on lactation (Spiedel, Ravenholt, and Irvine 1974), and 3) the problem of remembering to take them.  All factors considered, oral contraceptives may be the poorest method for preliterate people such as the Akha to use.

 

                                                Acceptance of Contraceptive Injections

 

The Upjohn Company has been making Depo-Provera (often called DMPA after its chemical name) since 1960.  Beginning in 1964 it has been used widely among Thai women in Northern Thailand in the McCormick Program (International Planned Parenthood Federation 1977, McDaniel and Partdthaison 1974).  A one cc. dose is effective for almost three months, and a three cc. injection will give protection for approximately six months.

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When we saw Akha women increasingly reject oral contraceptives, we started giving DMPA injections instead.  The field worker was instructed not to inject women who had high blood pressure, or those who were currently sick.  The reason for the first precaution was medical, the second was psychological.  Our medical advisor feared that if a sick woman got the injection, she might think that the injection would cure the sickness, and thus bring our program into disrepute when she remained sick.  Furthermore, if she eventually died after the injection, the DMPA might be blamed for the death, even though unrelated to it.  Another precaution we followed was not to inject a woman who had never had a pregnancy.  Our medical advisor warned that if a woman, not knowing she was sterile, received the injection, and later wished to become pregnant but could not, she might blame her failure on the injection.

 

When the field worker started giving contraceptive injections, the oral contraceptive program was almost completely stopped, and we began to get a much higher rate of contraceptive acceptance (see figure 3, page 131).  There was still a great deal of misgiving on the part of many Akhas, however, even toward the injections.

              [--note to editor: this graph needs to be scanned in--] Figure 3: Injections of DMPA to Akhas (four-month interval)             p.131

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The main disadvantage of DMPA is the fact that in a few women it causes very heavy bleeding, and in almost all other women it causes a change of the normal menstrual bleeding pattern so that there is usually light, infrequent bleeding, followed usually by amenorrhea after two or more injections.  In May 1975 there were two Akha women in the same village who developed severe bleeding problems from the injection, in spite of the fact that they took (or at least said they did) the Estrovis capsules the field worker had left with them for such emergencies.  The field worker told them that the program would pay their expenses to go to Chiang Rai and have their problems taken care of.  Because of the distance and time involved, they both declined this offer--but they also said "We will never take any contraceptive again."  This has probably had a deterrent effect on others in that and nearby villages.

 

Akha women give many vague complaints about not feeling well when they fail to have their periods.  These may well be psychosomatic for the most part, since they believe that the "old, bad blood" has to leave the body periodically in order to maintain good health.  For those who have spotty bleeding, it creates a problem as to when they can have intercourse with their husbands, since they feel it is dangerous for a man to have intercourse with a woman who is menstruating.

 

In spite of these disadvantages, there are some distinct advantages to the use of DMPA which have made it an excellent means of contraception for many Akha women:

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1) It is effective.  Less than one pregnancy per hundred woman-years of usage is reported (McDaniel and Partdthaison 1974).

 

2) It will not dry up the milk supply of a nursing mother (Zanartu et al. 1976).

 

3) It has good acceptibility on the part of the tribal people, who have come to feel that injectable medicines are far superior to oral ones.

 

4) A woman does not have to remember to take something every evening.

 

5) It will not harm the woman or the fetus if it is accidentally injected into a woman who is pregnant.

 

6) It is not related to the sex act.

 

7) It is reversible.

 

One of the most serious problems we faced in a practical way with DMPA, however, was the fact that so many couples could not pay for it.  The Akha Advisory Committee set the price of an injection at 75 cents (15 baht), saying that surely any couple that wanted help could pay that much.  In case after case, however, the injections were turned down simply because the family did not have the money.  The expense of the injections is a real obstacle to the spread of the program.  It requires ancillary programs to increase effective family income.

 

                                                 Acceptance of IUDs

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Intrauterine contraceptive devices cannot be fitted by our field worker, but need to be fitted by trained medical personnel in a hospital.  Nevertheless, we present it as another valid contraceptive method.  Akha women tend to reject this method for several reasons:

 

1) They do not like to have anyone (even a woman) deal in such an intimate way with their private parts.

 

2) They do not like the prospect of making the trip to the hospital for the initial fitting and then returning every other year to have it checked.

 

3) They do not like the fact, which we explain, that there is a fairly high failure rate with IUDs.  An Akha woman who is ready for this contraceptive aid is usually at the point where she does not want a single "failure".

 

Our program cannot recommend IUDs veryhighly for other reasons as well.  Sometimes an IUD perforates the uterus, and must be removed from the abdominal cavity by surgery(Povey and Silverman 1971).  The IUD sometimes causes bleeding, especially when the wrong size is used.  Then too, any infection in the uterus (especially VD) will flare up badly after the fitting of an IUD.

 

Even with the very best fitting IUD, there are afew women who cannot wear the device.  In some instances there is a spontaneous expulsion of the IUD, and if the woman does not realize it has come out she may get pregnant.

 

As far as I know, no Akha woman has had an IUD fitted as a result of our program, although there were some who had it before the program began.  Almost all of those women came in for sterilization when that part of our program began.

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                                           Continuation Rate of Reversible Methods

 

As can be seen in Figure 3 (page 131), the continuation rate of those who accepted reversible methods was not too good, certainly not as good as in other programs.  Among the Thai, for example, McCormick reports about 73% continue use of DMPA after one year, 57% after two years, and 46% after three years (IPPF 1977:14).  In our program, if the women who accepted sterilization following DMPA injections are included, we had almost 57% continuing after the first year, and slightly more than 33% continuing after the second year.

 

At first I wondered if a contraceptive that was technically highly acceptible to Akhas, simple to use, and with minimal side effects would not make a great difference in the number of acceptors and the rate of continuation.  From my interviews and observations, I now believe that the intensity of the desire for contraception on the part of the couple is far more important than excellence of the device or method used.  Strong desire to prevent another pregnancy, even though coupled with a relatively poor technique (pills, for example) results in a good rate of continuation of the method (provided no other better method comes along).  Moderate motivation, on the other hand, even with a relatively good technique (DMPA), usually results in a poor rate of continuation.

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A cogent example of this happened during the program: women from Burma pleaded with me for contraceptive help.  Because of legal problems we could not provide them with injectables.  I was able to send thousands of cycles of oral contraceptives across the border legally, and hundreds of Akha and Lahu women are reportedly taking those pills.  Their desire for contraception is so strong that in spite of the side effects and bother, they are willing to take such pills.

 

The fact that reversible contraceptive methods were less satisfactory than they had hoped for, led many Akha women to the irreversible method, sterilization, when it became available.

 

                                           Acceptance of Female Sterilization

 

There are two major types of sterilization: one is postpartum, performed shortly after a baby has been born.  The other is interval sterilization, which is done at a time not related to the birth of a baby.

 

For nearly all of the Akha couples seeking contraceptive aid, postpartum sterilization turned out not to be a viable option, which is true of 80% of the Thai couples in Thailand as well (Kamheang 1976).  Akhas give birth to their children at home, except in very unusual circumstances.  The only Akha woman I know to have had a postpartum sterilization is the wife of the Akha fieldworker.  By far the most practical thing for Akhas is the interval sterilization via tubal ligation, which our program has been offering to women since March 1974.

 

Table 4 (page 138) shows the extent to which tubal ligation was accepted by Akhas as well as the other tribal groups, both in Thailand and Burma.  This reveals that the average Akha woman living in Thailand who had the operation was 33.5 years of age, had 4.64 living children (with 55.7% of them boys), and had had an average of 1.78 loss through death and miscarriage.  This can be compared with the average woman which came from other ethnic groups (from both Thailand and Burma): the average age of the woman was 28.7, she had 4.27 living children (with 50.5% of them boys), and had an average loss through death and miscarriage of 1.36.

 

Table 5 (page 139) indicates that the 815 Thai women who accepted sterilization between November 1974 and April 1977 in the Chiang Mai Christian Clinic had an average age of 30.7, with an average of only 3.0 living children, and an average rate of 0.57 loss through death and miscarriage.  Of the Thai women, 89.3% had used some contraceptive method before coming for a sterilization, as opposed to only 49.5% of the Thailand Akhas, and 7.6% of the Burma Akhas.  

                           

                            Table 4: Tribal tubal ligation                                                                         p.138

                            Table 5. Comparison of sterilizations among Thai and tribal women                                            p.139

 

Some change has taken place over the period of time that the program has been in progress, although in just a few years it is difficult to substantiate specific patterns.  At first we tended to have older women with a fairly large number of children, who came in for sterilization in a somewhat panicked condition.  "Please help me before I have another pregnancy!" was their plea.  Later, from these same villages, younger women with fewer children came for sterilization, which led me to think at the time that from the beginning of the program to the end, both the age of the women and the number of children they had when coming in for sterilization would decline.  That has not happened.  A comparison of those who came the first twelve months and those who came the last twelve months show these two variables to be almost the same, for what actually took place was that though younger women with fewer children were coming from the villages first reached, there were older women with more children coming in from more distant villages at the same time.

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A difference can be seen between the Lahu and Akha women who have had the operation: the Lahu women average five years younger, and have a smaller percentage of living sons when they come for the operation (only 49.8% boys, compared to 55.7% boys for the Akhas).  Akhas tend to wait to be sure they have enough boys before they have the operation.

 

The location of the villages from which women came for sterilization indicates the following pattern: those living closest to Thai settlements were usually the first ones to come.  They had had more contact with the field worker, and often I had been to their villages as well.  After about eighteen months, we saw a decrease in the number of such women and an increase in the number who had to come from long distances.  The same pattern held when women from Burma came.  First the ones from near Mae Sai asked for the operation, then gradually from further north, until toward the end we had several Akha women coming all the way from Kengtung town to get the operation.

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Figure 4 (page 142) indicates the number of women from all tribes who accepted sterilization from October 1973 through July 1977, and Figure 5 (page 143) indicates the same thing just for the women from the Akha tribe.  The shaded portion in Figure 4 indicates the monsoon season, when it was more difficult for the tribal people to come.

 

The age-parity grid found in Table 6 (page 144) shows the number of Akha women from Thailand who received sterilization according to their age and the number of living children they had when they came in for the operation.  Table 7 (page 145) indicates the same thing for the Akha women who came from Burma.  A comparison of the two tables indicates that it was a younger group that came from Burma, with fewer children, whereas the older women from Thailand had more children than the women from the Burma side.  Those women with four or less living children make up 54.1% of the Thailand group, whereas those coming from Burma make up 62.4% of the group.  Also, those women with seven children or more make up 15.6% of the Thailand Akhas, while only 7.1% of the Akha women from Burma are in that category.

 

Table 8 (page 146) gives the age and parity of Thai, Akha and Lahu women who have been sterilized.  Significant differences can be found between the Thai of Bangkok and Chiang Mai, as well as the Akha of Thailand and Burma.  The differences between the Akhas of Thailand and the Thai women of Chiang Mai are the most contrastive.

 

Figure 4: Rate of female sterilization (all groups)                                                                                     p.142

Figure 5: Rate of sterilization: Akha women only                                                                                     p.143

Table 6.  Age-parity grid for women accepting sterilization--Akha women from Thailand                                                  p.144

Table 7.  Age-parity grid for women accepting sterilization--Akha women from Burma                                                     p.145

Table 8.  Comparison of Women who have been Sterilized                                                                                    p.146

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As can be seen in Tables 6 and 7, there are three women with no living children who were given the operation.  One was a twenty-two year old unmarried girl who was severely retarded mentally.  Her case was brought to the Akha Advisory Committee by her father (then 'village priest' of the largest Akha village in Thailand), and approved for the operation.  Two women from Burma were both married, and both had had several miscarriages.  One had almost died in childbirth, and on physical grounds a doctor in Burma strongly urged her to have the operation.  The other one could not urinate when she became pregnant, and had had three miscarriages.

 

Certain other women were accepted who had less than three living children.  They had problems such as: a rheumatic heart, tendency to have spontaneous abortions at each pregnancy, inability to give birth without medical aid (which is difficult when living in a remote village), etc.  There were some eleven couples who had less than three children each that we turned down (three of these were Akha), because we felt there was no compelling reason to give sterilization at that time.

 

When asked why they prefer sterilization over other methods, some Akhas give the following advantages:

 

1) It is free.  The program pays for their hospital services, and for their travel.

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2) It is effective.  Of the 1,351 women we have sterilized so far only one Lahu woman has had another pregnancy.

 

3) It is safe.  The women can be out working in the fields again within a couple of weeks after the operation.  There have been no fatalities.

 

There are certain disadvantages to sterilization as well:

 

1) It is irreversible.  If the couple should later want more children--in the event, for example, that one or more of their children should die--there is no way of reversing the operation with our facilities.

 

2) Complications can take place, such as the possibility of burning a bowel when cauterizing the tubes (Philips et al. 1976, Thompson and Wheeless 1973).  This has not happened in our program, since we have an experienced and careful doctor.

 

3) It cannot be done in the village.  Travelling to the hospital sometimes poses problems, as the time three Akha women coming in during rains could not cross a flooded stream.  Also, many who want to come in have no money for car fare.  They know that I will reimburse them when they get there, but they cannot pay even the original expense.

 

4) Akha women do not like to have an abdominal scar because they wear their skirts very low, thus exposing a fair amount of the abdomen.  Thanks to the laparoscope (which requires only a small incision) and a skillful surgeon who cares, there is very little complaint about this from Akha women.

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5) There is a danger that funding organizations will push projects hard to get the largest number of sterilizations possible--whether people really make the choice freely or not.  This can have a backlash effect on the program, as is reported to have happened in India.

 

                                                        Male Methods

 

The use of condoms as possible contraceptives is one that the Akhas themselves have virtually ruled out for various reasons.

 

Two basic reasons lie behind their refusal to undergo vasectomies: 1) anything having to do with pregnancy, delivering the baby etc. is considered women's work, and 2) there is a nagging concern that something might happen so that the man could no longer cut the trees to clear the fields for planting rice.  There is still a belief in the back of their mind that vasectomy must be a type of castration.

 

                                                        Rejection of Abortion

 

Akhas as a group do not accept abortion since they feel it is a threat to the 'line,' and feel sure that the ancestors will not let such actions go unpunished.  Tietze and Bongaarts (1975:119) feel that "it is unlikely that any population has ever attained a low level of fertility without the use of induced abortion, legal or illegal."  Japan was able to bring the crude birth rate from 34 to 18 per 1,000 in just eight years, primarily by means of abortions (Cox 1970).  At the same time, they then had very little by way of contraceptive aid (Wagatsuma 1970).

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It has been reported that when performing tubal ligations, some doctors in Bangkok automatically perform a curettage on any woman who is unprotected by contraceptives and is more than ten days past her menstrual period.  In the strict sense of the word, this would not be an "abortion," although there of course would be the possibility that some of the women might unknowingly be pregnant at the time.  This precaution would no doubt be good for the Akha program, and probably acceptible to them at this point, but it takes too much of the doctor's time to be practical.